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The nurse is caring for a client hospitalized for pelvic inflammatory disease (PID) who is discovered to have a ruptured pelvic abscess. Which nursing action is the priority at this time?
- A. Prepare the client for surgery.
- B. Administer antibiotic therapy as prescribed.
- C. Provide intravenous fluid replacement.
- D. Encourage bed rest.
Correct Answer: A
Rationale: A ruptured pelvic abscess requires emergency surgery. Administering antibiotic therapy as prescribed, providing intravenous fluid replacement, and encouraging bed rest are all appropriate actions, but they are lower priority for a client with a ruptured pelvic abscess.
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A client who wishes to preserve childbearing ability asks the nurse to explain how taking oral contraceptives will work in the management of endometriosis. Which is the best response by the nurse?
- A. Symptoms of endometriosis are increased during normal menstrual cycle.
- B. Conraceptives will allow blood to be diverted to the peritoneal cavity.
- C. Trapping blood causes less pain and discomfort for clients with endometriosis.
- D. Endometriosis is usually cured with surgical menopause.
Correct Answer: A
Rationale: The use of estrogen-progestin contraceptives keeps the client in a non-bleeding phase of the menstrual cycle, therefore decreasing ectopic tissue from shedding and causing extra uterine bleeding. Blood that is trapped in the peritoneal cavity causes more pain or adhesions form. Endometriosis is cured by natural or surgical menopause but can be medically instituted for periods of time with the use of oral contraceptives.
A client with extensive endometriosis is scheduled for a panhysterectomy. Which statement by the client indicates a need for further teaching?
- A. I will be having my uterus, tubes, and ovaries removed.
- B. I am finished having children.
- C. I will not have to deal with symptoms of menopause.
- D. I will now have a greater risk for stroke and heart disease.
Correct Answer: C
Rationale: Surgical menopause causes a sudden drop in estrogen and progesterone levels resulting in varied symptoms in clients. The risks of heart disease and stroke increase with estrogen reduction. A panhysterectomy is the removal of the uterus, both tubes and ovaries and will result in the inability to conceive children.
The nurse is collecting assessment data on a client who is reporting a vaginal discharge that is cottage cheese-like in appearance. Which pathogen is the most likely cause for this symptom?
- A. Gonococci
- B. Candida albicans
- C. Trichomonas vaginalis
- D. Gardnerella vaginalis
Correct Answer: B
Rationale: Candida albicans is a yeast infection that presents with a thick, curdy white discharge. Gonococcus is the organism that causes gonorrhea and presents with a yellow, mucoppuntent discharge. Trichomonas vaginalis presents with a foamy, white foul-smelling discharge and Gardnerella vaginalis is a watery, fishy-smelling discharge.
Following a radical vulvectomy, the nurse is preparing the client for discharge to home. Which care intervention would be considered the priority for this client?
- A. Relieving edema to lower extremities
- B. Alterations for sexual function
- C. Prevention of wound complications
- D. Care of colostomy site
Correct Answer: C
Rationale: Prevention of complications and infection is paramount due to the location of the wound. The perineal area provides a warm, dark environment that supports the growth of microorganisms that can be introduced into the wound. With a radical vulvectomy, is is likely to find surgical drains and urinary catheter that can also interfere with the maintenance of the wound. Relieving edema to the lower extremities may be a necessary part of care if the lymph nodes and blood vessels are disturbed. The client may have a colostomy and care instructions should be provided. Alteration in sexual function needs to be addressed but is not a priority for the initial stage of healing.
A client reports loss of interest in sexual relations and discomfort during intercourse. Which is the best response by the nurse?
- A. Don't worry, every woman goes through this.
- B. These are normal, manageable symptoms of menopause.
- C. You need to discuss this with your spouse.
- D. Hormome replacement therapy can resolve your symptoms.
Correct Answer: B
Rationale: Diminished libido and/or dyspareunia are common symptoms associated with perimenopause. Explaining that this can be a normal finding may help to alleviate worries for the client and provide hope for management of the symptoms. The nurse should avoid telling a client 'not to worry' or 'talk to someone else' because these can negate client feelings and shut down communication. HRT may not be recommended for this client.